diagnosis of device thrombosis...advanced heart failure center of excelle nce adapted from mehra et...

Advanced Heart FailureCenter of Excellence

Diagnosis of Device Thrombosis

Andrew Civitello MD, FACCMedical Director, Heart Transplant ProgramDirector, Advanced Heart Failure Fellowship

Co-Director, Advanced Heart Failure Center of ExcellenceBaylor St. Luke's Medical Center / Texas Heart Institute


Adapted from Mehra et al, J Heart Lung Transplant 2014;33:1-11

Trends in Patient Profiles, LVAD Volumes and Management Strategies

Secu

lar

Tren

ds

Implant Year 2008 2009 2010 2011 2012 2013

GI bleeding and vWF deficiencyLow reported thromboembolic events

Relaxed anticoagulation targetsReduced emphasis on post-op bridging

Aortic valve pathology emergesLower pump speed for AV openingM

anag

emen

t Co

nsid

erat

ions

Spike in HeartMate IIThrombosis


• Development of clot within the flow path of any the pump components:

• Inflow cannula

• Pump housing / rotor

• Outflow graft

• Thrombus may originate in the pump, or

• from the left atrium or ventricle, or

• from right sided chambers and travel through a septal defect

• And lodge in any, or all, of the pump components

Definition of Pump Thrombosis

Goldstein, J Heart Lung Transplant 2013


LVAD Thrombosis

Rotor

Outflow Cannula

Inflow Cannula


Scandroglio, et al J Am Coll Cardiol. 2016;67(23):2758–68

Diagnosis of Pump Thrombosis May be Elusive

Tchantchaleishvili et al Ann Cardiothorac Surg 2014;3(5);490-495


Adapted from Goldstein et al, J Heart Lung Transplant 2013:32;667-670

Algorithm for the Diagnosis of Suspected LVAD Thrombosis


Diagnosis of VAD Thrombosis - 2018

Adapted from Rame and Birati, J Am Coll Cardiol HF 2015;3 (11); 857-858

Assess other causes of HF or change in pump parameters

Normal

Admit to HospitalConsider intravenous anticoagulation

>3X Upper Normal Limit

Check LDH

Clinical Suspicion of VAD Thrombosis (At least one of the following):• Signs of Symptoms Suggestive of VAD thrombosis• Evidence of hemolysis• Change in pump parameters


Thrombus Formation

Hemolysis, but NoHemodynamic Compromise

Incomplete Thrombosis

Hemolysis, withAbnormal PumpFunction

Complete Thrombosis

Pump Stop WithCardiogenic Shock

The Relationship Between Hemolysis and VAD Thrombosis

Blitz, Ann Cardiothorac Surg 2014;3(5):450-471


Elevated LDH Levels Within 3 Months After HM II Implantation

Starling et al, N Engl J Med 2013;370:33-40


Shah et al, J Heart and Lung Transplant 2014:33;102-104

LDH and Serum Free Hb as Markers of Device Thrombosis


Consider Pump Exchange or OHTNo



Diagnosis:Echo Ramp studyHigher peak powerConsider CT angioConsider RHC


Normal

HM II HVAD

Yes

Hemodynamically Stable?



Check LDH



Echocardiography for Device Thrombosis

Increased LV size by LVIDd after LVAD thrombosis

Stainback et al, J Am Soc Echocardiogr 2015;28:853-909.)


Echocardiography Ramp Test - Diagnosis of Device Thrombosis

Increased AV Opening Time by M-mode




Low Velocity Inflow Cannula Peak velocity




Abnormal Inflow Cannula Colorflow



LVAD Ramp Study: Normal Patient LVAD Ramp Study: Thrombosis Patient

Normal vs Device Thrombosis RAMP Echo Study

Uriel et al, J Am Coll Cardiol 2012;60:1764-75


Ramp Echo Study - Normal vs Device Thrombosis



Ramp Echo Study - Normal vs. Device Thrombosis

LVEDD Slopes

LDH Values

Obstruction to Flow

No Obstruction to Flow

No Obstruction to Flow

Obstruction to Flow


No patient with VAD Thrombosis had a

LVEDD Slope <- 0.16

Best LDH Cutoff>1103

(5X ULM)


LVEDD Slope > -0.16 LVEDD Slope < -0.16RAMP echo

Check for Hemolysis: LDH, Plasma Free HemoglobinCheck Anticoagulation: INR, PTT

Using RAMP Echo Studies to Predict VAD Thrombosis

Adapted from Uriel et al, J Am Coll Cardiol:60;1764-75

Suspected Device MalfunctionLDH Elevation, Power Spikes

Device Thrombosis is Likely No Device Thrombosis or Malfunction







Normal

HM II HVAD

Yes



>2.5X Upper Normal Limit

Check LDH



Computed Tomography Angiography (CTA)

• Helpful in diagnosing mechanical issues predisposing to pump thrombosis

• Important positive findings include:

- Left ventricular thrombus

- Dilated left ventricle

- Cannula malposition toward any of the left ventricular walls

- Outflow graft thrombus, kinking or twisting

- Lack of opacification of the outflow graft

Blitz, Ann Cardiothorac Surg 2014;3(5):450-471Birati et al Curr Treat Options Cardio Med (2015) 17: 2


Misdirection of the apical cannula toward the interventricular septum


Milano et al, J Heart Lung Transplant 2011;30:838–40



Krishnan et al, J Cardiovasc Comp Tomography 2014;8:473-474

Mural thrombus in the proximal LVAD outflow cannula




Diagnosis:• Log file analysis• Higher peak powerConsider CT angioConsider RHC




Normal

HM II HVAD

Yes




Check LDH



RAMP Echo Slope Does Not Diagnosis HVAD Thrombosis

Uriel et al, J Cardiac Fail 2015:21;785-791


HVAD Log File Analysis to Diagnosis Thrombosis

Najjar et al, J Heart Lung Transplant 2014;33:23–34




Diagnosis:Log file analysisConsider CT angioConsider RHC


Diagnosis:Echo Ramp studyIncreased peak powerConsider CT angioConsider RHC


Normal

HM II HVAD

Yes




Check LDH



Questions?

diagnosis of device thrombosis...advanced heart failure center of excelle nce adapted from mehra et...

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